nhs west midlands chronic wounds toolkit

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[CHRONIC WOUNDS TOOLKIT] NHS West Midlands guide for quality in the commissioning and delivery of chronic wound prevention and treatment services

Chronic Wounds Toolkit 2010

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Contents

Glossary

1. Executive Summary

2. Introduction

a. Background

b. How was the toolkit developed?

c. Definition of chronic wound

d. Costs associated with chronic wounds

3. Requirements of commissioning services

a. How should the tool kit be used?

b. Structure of the toolkit

4. Quantifying the burden of chronic wounds

a. Identifying local priorities

b. Monitoring chronic wound prevalence management

c. Measurement of the effectiveness of wound care services

5. The right training at the right time

a. The value of education

b. Minimal skill sets and competency frameworks

c. Identifying the frequency of training

d. The role of care bundles

e. Commissioning expertise/developing experts

6. What can be done to prevent chronic wounds?

a. Can chronic wounds be prevented?

b. Services aimed at prevention

7. Clinical Pathways

a. Reducing variation in the management of chronic wounds

b. Rejecting tolerance of chronic wounds

c. The role of expert referral


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d. The role of innovation

e. Health Economy Working

8. Patient involvement

a. Patient information

Appendix 1 Chronic Wound Guidelines

Appendix 2 Members of Working Group

Appendix 3 Chronic Wounds Data Capture System

Appendix 4 Pressure Ulcer Productivity Tool

Appendix 5 Example multidisciplinary minimum skills set

Appendix 6 Chronic Wounds High Impact Intervention

Appendix 7 Heart of Birmingham PCT Pressure Ulcer Programme

Appendix 8 Wolverhampton City PCT Pressure Ulcer Prevention Bundle (in patient care) Appendix 9 Stoke on Trent Community Health Services Primary Care Foot Ulcer Pathway Appendix 10 Stoke on Trent Community Health Services Secondary Care Foot Ulcer Pathway Appendix 11 Stoke on Trent Community Health Services New Patient Referral Pathway Appendix 12 Example expert referral guidelines


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Glossary

Leg ulcer

Pressure ulcer

Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result

of pressure, or pressure in combination with shear.

Diabetic foot ulcer

A wound of the lower leg associated with the complications of diabetes

Non-healing surgical wound

A wound healing which fails to heal within the expected time frame post operatively

Wound healing by secondary intention

Wounds left open to allow the free drainage of exudate and the formation of granulation tissue

to fill the cavity left by removed tissue.

Recurrence

The presence of a wound on a previous site due to the same physiological cause

Prevalence

The proportion of a defined population who are affected by a disease.

Incidence

The rate at which new cases occur in a population during a specified period.


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1. Executive Summary

Chronic wounds have been identified as the sources of infection in as many as 40% of MRSA

bacteraemia cases within the West Midlands and are likely to be implicated in may other causes

of blood stream infection resulting in potentially avoidable harm to patients. The impact of

chronic wounds has not only debilitating implications but requires significant resources across

the health care system to treat the wound and the associated co-morbidities.

There is currently little data collected to give an indication of the number of chronic wounds

either across the West Midlands or within health economies or outcome data. This makes it

difficult to establish the resources required or indeed where there are gaps within in current

service provision.

The Chronic Wound Toolkit has been designed to support the commissioning and delivery of

services to understand the numbers of chronic wounds within the health economy, benchmark

current practice and align best practice to enable improved clinical outcomes. It will also

support provider organisations in the standardisation of services aimed at this important aspect

of patient safety.

This is achieved through:

Understanding the problem through effective data capture and monitoring

Consistent pathways of care with effective assessment and intervention, risk triggers

and timely escalation

Implementation of best practice as shared through service models and high impact

interventions.

This toolkit complements the Chief Nursing Officers High Impact Actions on Pressures Ulcers,

QIPP Safe Care work stream and the Diabetes UK ‘Putting Feet First’ campaign as well as NICE

and other national and international guidance on best practice. Whilst the high impact action

‘Your Skin Matters’ focuses on prevention of pressure ulcers, the chronic tool kit provides a

focus for assessment and management of chronic wounds including pressure ulcers.


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2. Introduction

a. Background

Currently 40% of MRSA bacteraemia cases reported to the West Midlands SHA have

their source identified as a chronic wound (West Midlands RCA data; 2009). The

prevalence of other organisms causing infection in chronic wounds is unknown but

these will be significant causes of blood stream infections as they migrate from the

wound to the circulatory system resulting in acute care admissions, complicated

antibiotic regimes and the associated risk of mortality.

Chronic wounds are complex in their cause, duration, management and

complications; infection being just one. The burden of chronic wounds on healthcare

services in the UK is significant as identified in the in the Chief Nursing Officer’s high

impact actions for nursing and midwifery which highlight the burden of pressure

ulcers, just one group of chronic wound but one which safeguarding boards are

increasing concerned with. The opportunity to improve on quality, productivity of

wound care services and prevention of disease in the West Midlands is likely to yield

substantial cost benefits and significantly improve the patient experience.

Despite the complexity of these wounds, focus on prevention, early intervention,

referral and specialist treatment pathways have been shown to be highly effective in

the timely healing and prevention of chronic wounds. Implementing a chronic

wound prevention and reduction strategy as a Quality Innovation Productivity and

Prevention (QIPP) initiative will have the following benefits:

Assisting organisations to deliver the forthcoming years MRSA Objective.

Reduce pressure on community provider services

Prevent admissions associated with chronic wounds and their complications

Reduce costs associated with wound dressings and associated technologies

Increase patient satisfaction

Improve quality of services

Prevent unnecessary associated morbidity and mortality

Deliver one of the Chief Nursing Officer’s high impact actions for nursing and

midwifery (No avoidable pressure ulcers in NHS provided care)

Supports the QIPP Safe Care work stream and the Energising for Excellence

Campaign

http://www.endoflifecare.nhs.uk/eolc/files/NHSI-High_Impact_Actions-Nov2009.pdf

http://www.endoflifecare.nhs.uk/eolc/files/NHSI-High_Impact_Actions-Nov2009.pdf


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National and international guidance and best practice principles exist for the

purposes of prevention, treatment and holistic care of chronic wounds (see

appendix 1) however, variability of their implementation is a recognised problem.

This variability has been attributed to:

Patient related factors (co-morbidities, compliance, environment and

psychosocial wellbeing);

Wound related factors (duration, size, condition, infection, wound location);

The skill and knowledge of the healthcare professional (competence in wound

assessment and measurement, triggers for expert referral);

Resources and treatment related factors (habitual behaviour, wound care

formularies, delayed innovation, improvement measures)

(Adapted from Vowden et al, 2008)

This document aims to identify how commissioners and providers can ensure that

chronic wounds are monitored and reduced through the use of a series of tools and

examples of good practice in the region. It has been developed with the assistance

of regional experts in the field.

b. How was the tool kit developed?

A workshop to identify the contributing factors to the variability in chronic wound

service provision in the West Midlands was held in Birmingham. Key experts in

infection prevention and tissue viability were invited from three West Midland

health economies thought to be particularly dynamic in this area. During the

workshop the following areas were considered:

What is a chronic wound?

What patient groups are likely to have chronic wounds?

Where are the patients?

Who looks after the wounds?

What components does a good wound care service need to have?

Results of the workshop revealed wide variation in the delivery of services. No

health economy provided consistent preventative and expert treatment and referral

services, education and patient information relating to chronic wound management.

Furthermore there was very little evidence of measurement of chronic wounds or

performance indicators aimed at rapid healing or appropriate care of the wound.


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Following the workshop a multidisciplinary working party was set up as a task and

finish group to develop guidance, pathways and best example case studies. These

are targeted at commissioners and providers and aim to drive down the numbers of

chronic wounds through ensuring expert referral pathways are in place and

measuring performance against key standards. Examples of best practice were

sourced from regional interest groups and their networks. Full details of members of

the working group are provided in Appendix two. The diagram below shows the

outline strategy developed.

c. Definition of chronic wound

Definitions of chronic wounds are based on either the aetiology or the duration of

the wound. For the purpose of this document a definition based on duration is taken

as it is likely to facilitate effective measurement of improvement.

IMPROVED QUALITY AND SAFETY

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A chronic wound is defined as any wound which has remained unhealed for longer

than 6 weeks (Cutting & Tong 2003).

Chronic wounds are likely to include the following:

Pressure ulcers

Leg ulcers

Diabetic foot wounds

Non-healing surgical wounds/wounds healing by secondary intention

Traumatic wounds.

d. Costs associated with chronic wounds

The costs of chronic wounds are largely unknown. This is mainly due to the diversity

of settings where they are treated and medical professionals to whom responsibility

for their management falls. The cost of pressure ulcers has been estimated as £1,064

for a grade one pressure ulcer rising to £24,214 for a grade 4 pressure ulcer (NHS

Institute for Innovation and Improvement, 2009). Venous leg ulcers have been

estimated as costing the NHS at least £168–198m per year (Posnett and Franks;

2008) and diabetic foot ulcers are estimated to cost an estimated £300m per year

(Gordois et al, 2003) with estimates that 50% of these will become infected at some

time (Lavery et al, 2003) and 2,600 will require lower limb amputation each year.


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3. Requirements of Commissioning Services

a. How should the tool kit be used?

It is recommended that commissioning services benchmark their services against

those explained in this toolkit. The local prevalence and resulting burden of chronic

wounds should be understood. Following this a gap analysis should be undertaken to

identify the necessary actions to ensure a comprehensive chronic wound service is in

place.

Key points are:

The local prevalence and burden of chronic wounds need to be understood along

with any priority areas

Local services should be compared to the recommended framework

A gap analysis should be undertaken followed by

A risk assessment to identify relevant action that needs to be taken.

b. Structure of the toolkit

The structure of the tool kit is designed to be user friendly and give easy access to

tools to assist with focus and improvement in this area. Cases studies and additional

tools will be added on a regular basis as experience develops and usage increases.

Individual tools are included as appendices to this document.


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4. Quantifying the Burden of Chronic Wounds

a. Identifying local priorities

The burden of chronic wounds is unknown in most health economies. From our

discussions we have found that that this is due to the wide variation in where

chronic wounds are managed, their definition, which health professionals their care

is managed by, and inconsistencies in data collection. Therefore there is a need to

collect data on all chronic wounds using a consistent methodology which is repeated

regularly or maintained as an ongoing surveillance system. Difficulty in comparing

and benchmarking data is externally experienced by many organisations due the

variances in socioeconomic backgrounds. It is therefore anticipated that

organisations set their own, regularly reviewed, ambitions for improvement in

ongoing prevalence data.

b. Monitoring chronic wound prevalence

The prevalence of all types of chronic wounds is needed to truly asses the extent of

the problem, to identify trends, effectiveness of services and monitor improvement

and cost and quality benefits. To facilitate this data collection and monitoring a

database has been developed by NHS West Midlands which is a simple, free to use,

secure, web based data entry system enabling PCO’s to download status reports.

However a commitment to data collection, entry and capture is required. See

appendix three for details of the data capture system developed by the working

group.

c. Calculating the cost of chronic wounds

Prevalence data can be used to calculate the financial cost of chronic wounds to

organisations. To assist with this the Chronic Wounds Calculator has been

developed. This tool relies on a number of assumptions and is detailed in Appendix

four.

d. Measurement of the effectiveness of wound care services

In order to decrease the burden of chronic wounds the change need to be owned at

Board level and the subsequent implementation of measures needs aimed at

reducing the prevalence of chronic wounds as well as improving the patient

experience, quality and safety. The clinical services involved (in which there are


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many) need to be engaged and bought into an ambitious strategy which creates an

expectation that the whole organisation will have a responsibility to contribute.

Local targets should be agreed against a range of measures which examine clinical

outcome and aspects of process. Suggested measures are listed below for the

intention of primary care organisations adopting a selection of these to measure

performance.

Suggested Outcome Measures

i. Time to heal

Number of new wounds healing with in 0-12 weeks, 12-24 weeks, 24-52

weeks, more than 52 weeks.

ii. Recurrence rates

Of the number of chronic wounds healed the percentages which recur in at

the same site within a 52 week period.

iii. Incidence of new onset of chronic wounds

iv. Patient satisfaction

Key questions should be asked of patients with chronic wounds to be able to

identify obstacles to rapid healing (e.g. access to services) and health status

(e.g. mobility).

Suggested Process Measures

v. Prevalence of chronic wounds expressed a rate per 10,000 population

(Include prevalence in care home setting)

vi. Percentage of patients with chronic wounds on a specialist pathway

vii. Number of hospital admissions with chronic wounds per 1,000 admissions

viii. Length of stay of patients with chronic wounds per 1,000 bed days

ix. The number of chronic wounds arising as a result of an inpatient care

episode

x. Training

NHS and private sector care settings can monitor the uptake of training and

maintaining knowledge and skills. See section 6 for appropriate training.


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xi. Compliance with relevant care bundles

Compliance being 100% and monitored at set intervals. Escalation plans to

monitor more frequently can be based on compliance scores and

maintenance of the agreed standards.

(See section 5d for more information on care bundles)

xii. Compliance with training requirements

(See section 5c frequency of training)


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5. The Right Training at the Right Time

a. The value of education

Good quality education is vital to improving services for those with chronic wounds.

Through appropriate training and education assessment of risk, interventions to

heal, reduce size or alleviate symptoms, as appropriate, and relevant referral of

chronic wounds to experts is more likely.

Education must be targeted at all those responsible for assessment and care of the

patient/client. It must include not only theoretical content relating to wound healing

and the skills required to undertake this but the ambition to reduce the burden of

chronic wounds and the triggers for referral to specialised services. In order that this

education is delivered consistently it should be multi faceted and inclusive. The

diagram below demonstrates where education should be targeted.

b. Minimal skill sets and competency frameworks

Education and training is required to be delivered in a practical manner, ensuring

that staff providing care and assessment gain practical knowledge to identify key

challenges relating to wound care and how to expedite the relevant care pathway.

•Multidisciplinary

•Consistent with clinical training/experiences

•Contemporary

Pre-registration

•Competency based

•Regular updates

•Monitoring of practice using care bundles

•Targeted education relating to performance/ audit results/initiatives

Post-registration

•Preventative

•Supportive of treatment

•Patient contracts

•Suport initiatives

Patient Education


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An example of a multi professional minimum skill set is developed by Birmingham

City University is provided in Appendix 5.

A minimum of 3 yearly updates is recommended for all staff with a responsibility for

the assessment or care of chronic wounds, this must include medical, nursing and

allied health professionals to ensure that patient safety is maintained.

See pages 18/19 for Dudley Primary Care Trust leg ulcer service solution to

education and competency assessment of district nurse’s leg ulcer assessment and

treatment skills.

c. Identifying the frequency of training

Organisations will need to identify all healthcare workers who have a role in chronic

wound management including relevant medical, podiatry, nursing and allied health

professionals. All should have competency assessment and at least 3 yearly update.

This should be monitored regularly for compliance with the training frequency.

Universities delivering pre and post registration training have a clear role to play in

strengthening the delivery of services. The provision of training should be both

classroom and placement orientated however, commissioners of training should

ensure that there is proof that expert clinical advice has been sought in influencing

the training programme to ensure that training is contemporaneous.

d. The role of care bundles

Care bundles link evidence and measurement thorough identifying key processes

aimed at reducing infection during a specific procedure or element of care. The

focus is on quality of care rather than research or judgment (Marwick & Davy, 2009).

High Impact Interventions are measurement tools based on this approach and

provide the opportunity through self or peer assessment to standardise key aspects

of clinical practice and a means of demonstrating compliance with a standard using

an agreed measurement. To succeed all elements of the care bundle must be

consistently undertaken.

A high impact Intervention focussing on chronic wounds has been developed by the

Royal Wolverhampton Hospitals NHS Trust and Wolverhampton City PCT (see

appendix 6). The Department of Health are also in the process of publishing a similar

document as part of the Saving Lives package. See link to the latest package of

initiatives below:


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www.dh.gov.uk/en/Publichealth/Healthprotection/Healthcareassociatedinfection/P

racticalsupport/SavingLives/index.htm

e. Commissioning expertise/developing experts

It is vital that clinical staff have access to experienced and trained tissue viability

experts to ensure timely healing of chronic wounds which are able to progress along

the healing continuum and overcome the many risks which potentially prevent this.

Tissue viability nurses, podiatrists, vascular and diabetic teams are often the source

of this expertise in the NHS, other organisations may subscribe to private providers

or commission additional services. Whichever system or combination is the

preferred, services should be able to offer:

Prevention services for leg ulcers, diabetic foot ulcers and pressure ulcers

Support to clinical staff dealing with non-healing or problematic wounds

Education and training to all healthcare workers and health professionals

Advice on current opinion, technologies and evidence in wound healing

Advice on local policy, wound care formulary and potential cost savings

Raise awareness of health lifestyles/disease prevention

Analysis of surveillance data to inform service priorities to meet the needs of

the given population

Audit of relevant services and practices.

http://www.dh.gov.uk/en/Publichealth/Healthprotection/Healthcareassociatedinfection/Practicalsupport/SavingLives/index.htm

http://www.dh.gov.uk/en/Publichealth/Healthprotection/Healthcareassociatedinfection/Practicalsupport/SavingLives/index.htm


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6. What can be done to prevent chronic wounds?

a. Can chronic wounds be prevented?

Preventative chronic wound services are essential and exist for many of the

categories of chronic wounds. As chronic wounds have varying causes the

preventative services differ. A summary and some examples of effective

preventative services/practices are listed below.

b. Services aimed at prevention

Diabetic Foot Ulcers

The 2008 prevalence of diabetes was 2.89% in England. It is estimated that 50% of

diabetic foot ulcers will be come infected with 2,600 cases per year requiring

amputation. Prevention is therefore essential for the safety of the patient and to

enable efficient use of resources. The Diabetes UK document Putting Feet First:

Commissioning specialist services for the management and prevention of diabetic

foot ulcers (2009) explains the role of acute trusts in the prevention of diabetic foot

disease in hospital inpatients. Community provider services should have suitable

podiatry services with the following emphasis

Education on foot care to all new patients with diabetes and their carers, focusing on prevention

Ongoing education of patients with diabetes and their carers

Education, advice, liaison, and outreach support to primary care diabetes teams. (British Diabetic Association, 1999)

In addition this service should actively seek out those at risk of diabetic foot ulceration, including younger people with diabetes and explore innovative ways of allowing them to access services (e.g. telemedicine). Leg Ulcer Prevention

The Royal College of Nursing Clinical Practice Guideline: the nursing management of

patients with venous leg ulcers (RCN, 2006) recommends that the clinical and

educational strategies should be available to prevent recurrence of venous leg

ulcers:

Clinical

http://www.diabetes.org.uk/Professionals/Publications-reports-and-resources/Reports-statistics-and-case-studies/Reports/Putting-feet-first

http://www.rcn.org.uk/development/practice/clinicalguidelines/venous_leg_ulcers

http://www.rcn.org.uk/development/practice/clinicalguidelines/venous_leg_ulcers


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Life time compression hosiery

Venous investigation and surgery

Regular follow up to monitor skin condition for recurrence

Regular follow up to monitor ankle brachial pressure index (ABPI)

Patient education

Concordance with pressure therapy

Skin care

Discourage self treatment with over-the-counter medicines

Avoidance of accident or trauma to legs

Early self-referral at signs of possible breakdown of the skin

Encouragement of mobility and exercise

Elevation of the affected limb when immobile. (RCN; 2006)

NHS Gloucestershire has developed a ‘Look after Your Legs Programme’ including

exercise video’s and CD’s, patient ambassadors, education material, inspection

advice and care instructions aimed at reducing the risk of recurrence of leg ulcers

www.healthylegs.nhs.uk .

Dudley Primary Care Trust runs 6 leg ulcer clinics across the borough to enable easy

access to leg ulcer treatment and prevention services. These are led by a tissue

viability nurse with a group of specialist leg ulcer and district nurses. The service

provides:

Expert assessment and care planning of patients with leg ulcers

Treatment of leg ulcers with a key aim of preventing recurrence

Expert advice and support to patients with healed wounds

Expert education and support to district nursing services.

Patients with healed leg ulcers are fitted with compression hosiery and provided

with information and education on the hosiery, skin care and when to seek advice.

The patients are then reviewed 2-3 weeks later to ensure the hosiery is effective and

information and education refreshed. Following this the patients are recalled 6 to 12

monthly for further assessment (depending on other risk factors such as diabetes),

hosiery renewal and education.

A relationship between the service and the patients is developed which enables

patients open access to seek advice and treatment at a much earlier point should

their skin begin to ulcerate again, reducing healing times and recurrence rates.

http://www.healthylegs.nhs.uk/


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The clinics provide important advice and support to community nurses but

education of this group is challenging due to the numbers involved, geographical

spread and demands on community services. Rotation of community nurses through

these clinics means that the service is adequately staffed and district nurses skills

and competency can be assessed and maintained. This has been successful in one

area of the 6 covered by clinics and is now planned to rollout to other areas.

Pressure Ulcer Prevention

NICE guidance on pressure relieving devices (2003) recommends the following

multiple strategies in order to prevent pressure ulcers

Identification of vulnerable individuals through risk assessment

Regular skin inspection

Positioning of the patient

Use of seating aids and equipment

Use of pressure relieving devices (beds, mattresses and overlays)

A comprehensive education programme.

Heart of Birmingham Teaching PCT has incorporated pressure ulcer prevention into

a broader pressure ulcer treatment and prevention programme aimed at preventing

recurrence of healed pressure ulcers. Nurses have access to a series of supportive

tools and educational information (see appendix 7).

Wolverhampton City Primary Care Trust provider (in patient) service has developed

a comprehensive care bundle aimed at prevention of pressure ulcers. In addition to

the risk assessment and the care plan, medication, mobility and nutrition are

assessed by the relevant allied health professional and a daily intervention sheet is

used to document the condition of pressure areas and trigger referral to the tissue

viability service or reassessment. This links to a Care Standard Guideline for Pressure

Ulcer management. Documentation is available in appendix 8.

http://www.nice.org.uk/nicemedia/pdf/CG7_PRD_NICEguideline.pdf


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7. Clinical Pathways

a. Reducing variation in the management of chronic wounds

The use of clinical pathways in the prevention and treatment of chronic wounds is

key to successful management. These must be contemporary and include room for

new and innovative therapies with clear triggers for referral and expert review.

Chronic wounds which fail to progress with current recommended therapy require

the patient to undergo regular re-evaluation to identify the factors inhibiting

progression.

Diabetic Foot Ulcers

An ideal diabetic foot ulcer pathway is provided in appendix 8.

Pressure Ulcers

NICE (2005) has published the management of pressure ulcers in primary and

secondary care: A Clinical Practice Guideline guidance as have EPUAP (2009)

Pressure ulcer treatment: quick reference guide.

b. Rejecting tolerance of chronic wounds

There has been an acceptance of chronic wounds both from health professionals

and those affected. Through the development of a strategy aimed at the prevention

and reduction of the number of chronic wounds costs and resources will be

released. Beliefs that chronic wounds cannot be healed need to be rejected by

healthcare professionals having contact with those affected. The following points

should be considered in strategy to assist in this element:

Create partnerships with service users

Gain board level champions who are aware of the necessary processes

Appeal to the core values of healthcare workers required to change

Ensure a whole organisation (grass roots to board) approach.

c. The role of expert referral

Clear guidance should exist to limit the duration of chronic wounds and allow

prompt expert intervention in wounds which fail to make progress. Local guidance

must make clear ‘triggers’ for referral. Appendix 9 gives the example of the referral

guidelines at Bradford Teaching Hospitals NHS Trust.

http://www.nice.org.uk/nicemedia/pdf/CG029fullguideline.pdf


http://www.epuap.org/guidelines/Final_Quick_Treatment.pdf


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d. The role of innovation

Recent years have seen an explosion of innovative wound dressings and

technologies. Innovations need to implemented and evaluated for their clinical

effectiveness, cost efficiency, user acceptability and their productivity. Clinical

pathways should allow for the introduction of innovation. Some examples of

innovations in wound care are listed below.

Platelet Leukocyte Gel (PLG)

Topical negative pressure wound therapy

o NICE guidance on the use of this technology for use in open

abdomens (2009) is available

Laser therapy

Larvae therapy

Antimicrobial dressings

http://www.nice.org.uk/nicemedia/pdf/IPG322Guidance.pdf



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8. The Role of Health Economies

Experts are often available in NHS organisations though there may be more than one

service with an interest in chronic wounds as discussed earlier. Health economies should

look towards establishing wound care formularies with shared or seamless policies, referral

criteria, pathways, and innovations. This should include the private and social care sectors,

charitable organisations such as hospices, local authority, pharmacy, infection prevention

and control services and senior organisational leaders. Such groups should monitor a local

strategy and improvement while identifying key areas of concern or action and consider the

representation of an expert patient (see section 9).

In organisations where NHS experts are not available innovative solutions should be sought.

Private providers who may provide ‘whole solution’ wound care service from prevention to

education and policy to treatment are available with many NHS organisations offering

service level agreements with the private sector.

Heart of England, Birmingham East and North and South Birmingham Primary Care Trusts

have developed a joint service led agreement to provide care homes with a suitable Tissue

Viability Team to provide advice and support to the care homes in these health economies.

A link to a full case study for this programme can be found at

www.institute.nhs.uk/building_capability/hia_supporting_info/your_skin_matters.html.

http://www.institute.nhs.uk/building_capability/hia_supporting_info/your_skin_matters.html


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9. Patient involvement

a. Patient information

NHS Choices has a comprehensive library of information for patients on chronic

wounds including videos, written information and links to specialist resources.

b. Patient involvement

Patient user groups are one way of ensuring that the interests of patients with

chronic wounds are best met. Including patients in decision making to shape and

monitor services may add ambition, empower the patient and ensure that the

patient is the focus of the strategy. The Expert Patient Programme (Department of

Health, 2001) aims to tap into the previously underutilised knowledge of patients

with long term conditions to improve care, particularly in relation to quality of life

issues.

References

Cutting KF, Tong A; 2003; Wound Physiology and Moist Wound Healing; Medical

Communications LTD; Holsworthy

Department of Health; 2001; The Expert Patient: A New Approach to Chronic Disease

Management for the 21st Century;

www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/

dh_4018578.pdf 8th June 2010

Diabetes UK; 2009; Putting Feet First: Commissioning specialist services for the management

and prevention of diabetic foot disease in hospitals;

www.diabetes.org.uk/Documents/Reports/Putting_Feet_First_010709.pdf 8th June 2010

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel; 2009;

Pressure Ulcer Treatment; www.epuap.org/guidelines/Final_Quick_Treatment.pdf 8th June

2010

Gordois A, Scuffham P, Shearer A, Oglesby A; 2003; The healthcare costs of diabetic peripheral

neuropathy in the UK; Diabetic Foot; 6:62-73

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4018578.pdf

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4018578.pdf%208th%20June%202010

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4018578.pdf%208th%20June%202010

http://www.diabetes.org.uk/Documents/Reports/Putting_Feet_First_010709.pdf

http://www.epuap.org/guidelines/Final_Quick_Treatment.pdf%208th%20June%202010



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Lavery LA, Armstrong DG, Wunderlich RP, Tredwell J, and Boulton AJM; 2003; Diabetic foot

syndrome: evaluating the prevalence and incidence of foot pathology in Mexican Americans

and non-Hispanic whites from a diabetes disease management cohort; Diabetes care;

26:5;1453-38

Marwick C, Davy P; 2009; Care Bundles: the holy grail of infectious risk management in

hospital?; Current Opinion in Infectious Diseases; 22:4 364-369

National Institute for Health and Clinical Excellence; 2003; Pressure ulcer risk assessment and

prevention, including the use of pressure-relieving devices (beds, mattresses and overlays) for

the prevention of pressure ulcers in primary and secondary care;

www.nice.org.uk/nicemedia/pdf/CG7_PRD_NICEguideline.pdf 8th June 2010

National Institute for Health and Clinical Excellence; 2005; The management of pressure ulcers

in primary and secondary care: A Clinical Practice Guideline

www.nice.org.uk/nicemedia/pdf/CG029fullguideline.pdf 8th June 2010

National Institute for Health and Clinical Excellence; 2009; Negative pressure wound therapy for

the open abdomen; http://www.nice.org.uk/nicemedia/pdf/IPG322Guidance.pdf 8th June 2010

NHS Institute for Innovation and Improvement; 2009; High Impact Actions for Nursing and

Midwifery; NHS Institute for Innovation and Improvement;

www.institute.nhs.uk/images//stories/Building_Capability/HIA/NHSI%20High%20Impact%20Ac

tions.pdf 8th June 2010

Posnett J, Franks PJ; 2008; The burden of Chronic Wounds in the UK; Nursing Times; 104; 44-45

Royal College of Nursing; 2006; Royal College of Nursing Clinical Practice Guideline: the nursing

management of patients with venous leg ulcers;

www.rcn.org.uk/__data/assets/pdf_file/0003/107940/003020.pdf 8th June 2010

Vowden P, Apelqvist J, Moffat C; 2008; Wound Complexity and Healing: In European Wound

Management Association; 2008; Position Document: Hard to Heal Wounds: a holistic approach;

http://ewma.org/fileadmin/user_upload/EWMA/pdf/Position_Documents/2008/English_EWM

A_Hard2Heal_2008.pdf 8th June 2010




http://www.institute.nhs.uk/images/stories/Building_Capability/HIA/NHSI%20High%20Impact%20Actions.pdf

http://www.institute.nhs.uk/images/stories/Building_Capability/HIA/NHSI%20High%20Impact%20Actions.pdf

http://www.rcn.org.uk/__data/assets/pdf_file/0003/107940/003020.pdf

http://ewma.org/fileadmin/user_upload/EWMA/pdf/Position_Documents/2008/English_EWMA_Hard2Heal_2008.pdf%208th%20June%202010

http://ewma.org/fileadmin/user_upload/EWMA/pdf/Position_Documents/2008/English_EWMA_Hard2Heal_2008.pdf%208th%20June%202010


25

Appendix 1 - Published Guidelines


Pressure Ulcer Treatment; www.epuap.org/guidelines/Final_Quick_Treatment.pdf 8th June

2010


Pressure Ulcer Prevention; www.epuap.org/guidelines/Final_Quick_Treatment.pdf 8th June

2010

International Working Group on the Diabetic Foot; International Consensus on the Diabetic Foot &

Practical Guidelines on the Management and Prevention on the Diabetic Foot

www.iwgdf.org/index.php?option=com_content&task=view&id=87&Itemid=138 8th June 2010

National Institute for Health and Clinical Excellence; 2003; Pressure ulcer risk assessment and

prevention, including the use of pressure-relieving devices (beds, mattresses and overlays) for

the prevention of pressure ulcers in primary and secondary care;

www.nice.org.uk/nicemedia/pdf/CG7_PRD_NICEguideline.pdf 8th June 2010

National Institute for Health and Clinical Excellence; 2005; The management of pressure ulcers

in primary and secondary care: A Clinical Practice Guideline

www.nice.org.uk/nicemedia/pdf/CG029fullguideline.pdf 8th June 2010

National Institute for Health and Clinical Excellence; 2009; Negative pressure wound therapy for

the open abdomen; http://www.nice.org.uk/nicemedia/pdf/IPG322Guidance.pdf 8th June 2010

National Pressure Ulcer Advisory Panel; 2009; NPUAP-EPUAP Pressure Ulcer Prevention and

Treatment;

Royal College of Nursing; 2006; Royal College of Nursing Clinical Practice Guideline: the nursing

management of patients with venous leg ulcers;

www.rcn.org.uk/__data/assets/pdf_file/0003/107940/003020.pdf 8th June 2010





http://www.iwgdf.org/index.php?option=com_content&task=view&id=87&Itemid=138




http://www.rcn.org.uk/__data/assets/pdf_file/0003/107940/003020.pdf%208th%20June%202010


26

Appendix 2 Members of Working Group and Acknowledgments

Name Title Vanessa Whatley Programme Specialist (Healthcare Associated Infection)

NHS West Midlands Helen Shoker Lead Tissue Viability Nurse

Walsall Hospitals NHS Trust Anna Pronyszyn

Infection Prevention Nurse Consultant NHS Sandwell

Gillian Hiskett Modern Matron Heart of Birmingham Teaching Primary Care Trust

Maria Poole Tissue Viability Nurse Wolverhampton City Primary Care Trust

Sarah Hart

Principal Podiatrist Diabetes & Tissue Viability Community Services Warwickshire Community Health

Lorraine Thursby

Service Lead Manual Handling and Tissue Viability George Eliot Hospital

Pat Davies Senior Lecturer Birmingham City University

Acknowledgement to :

Carole Clive Consultant Nurse Infection Prevention and Control; NHS Worcestershire

Debbie King Head of Infection Prevention Solihull Care Trust

Dr Beryl Oppenheim Consultant Microbiologist Sandwell and West Birmingham NHS Trust

Dr Jane Povey Medical Director NHS West Midlands

Ingrid Craddock Infection Prevention Nurse Wolverhampton City PCT

Iris Fitzgibbon Professional Head for Rehabilitation Nursing

Wolverhampton City Primary Care Trust

Dr Itisha Gupta Consultant Medical Microbiologist Heart of England NHS Trust

Jane Taylor Programme Lead (HCAI) NHS West Midlands

Karen Mc Bride Tissue Viability Nurse Dudley Primary Care Trust

Dr Kathryn Vowden Consultant Nurse Tissue Viability Bradford Teaching Hospitals NHS Foundation Trust

Maria Poole Tissue Viability Nurse Wolverhampton City PCT

Susan Harper Infection Preventions Nurse Royal Wolverhampton Hospitals NHS Trust

Podiatry Diabetes Group Stoke on Trent Community Health Services


27

Appendix 3 Chronic Wounds Data Capture System

http://www.monitoring.westmidlands.nhs.uk/Login.aspx?ReturnUrl=%2fDefault.aspx

For more details, user guide and registration enquires please email [email protected]

http://www.monitoring.westmidlands.nhs.uk/Login.aspx?ReturnUrl=%2fDefault.aspx

mailto:[email protected]


28

Appendix 4 Pressure Ulcers Opportunity Estimator (Calculator)

An Excel based resource for estimation of the financial burden of pressure ulcers, the

opportunity estimator, has been produced and is available on the ‘Your Skin Matters’ high

impact intervention pages of the NHS Institute for Innovation and Improvement pages. The

selected text provides the link to the pages below.

www.institute.nhs.uk/opportunity_locators/calculators/pressure-ulcers.html

http://www.institute.nhs.uk/opportunity_locators/calculators/pressure-ulcers.html

http://www.institute.nhs.uk/opportunity_locators/calculators/pressure-ulcers.html


29

Appendix 5: Example multidisciplinary minimum skills sets produced by Birmingham City

University

Untrained healthcare staff with clinical skills (e.g. Health Care Assistants)

Skin assessment

Equipment for pressure ulcers including repositioning

Wound Dressing

Bandage application

Aseptic / non-touch technique

Clean technique

Awareness of appropriate positioning techniques for patients with leg ulceration

Newly qualified clinical staff (e.g. Foundation year 1 doctors/nurses/Allied health professionals)

To be able to undertake a full skin Assessment

To be able to classify Pressure Ulcers correctly

To be able to risk assess patients for pressure ulcers using a recognised pressure ulcer risk assessment tool.

To be able to determine the appropriate equipment to use to prevent pressure ulcers including repositioning

To be able to determine the appropriate equipment to use to treat existing pressure ulcers including repositioning

To demonstrate an awareness of leg ulceration management

To demonstrate an awareness of the appropriate management of fungating wounds

To demonstrate an awareness of the appropriate management of open abdomen

To demonstrate an awareness of the appropriate management of the diabetic foot

To be proficient at aseptic / non-touch technique

To be proficient at clean technique

To demonstrates the ability to determine a wound infection and instigate appropriate management.

To be proficient in holistic wound assessment

To be proficient in determining appropriate wound management to include wound covering material.

To demonstrate proficiency in the taking of a wound swab from a non-infected wound and from an infected wound.

To have an awareness of the need for health promotion in order that patients become experts in their own wound management.

Demonstrates the ability to plan the appropriate care for a patient with a wound; including the use of appropriate treatment objectives to enable evaluation.

Clinical staff having completed foundation stage/preceptorship

To be able to undertake a full skin Assessment and be able to teach this to others.

To be able to classify Pressure Ulcers correctly and be able to teach this to others.

To be able to risk assess patients for pressure ulcers using a recognised pressure ulcer risk assessment


30

tool and be able to teach this to others .

To be able to determine the appropriate equipment to use to prevent pressure ulcers including repositioning and be able to teach this to others.

To be able to determine the appropriate equipment to use to treat existing pressure ulcers including repositioning and be able to teach this to others.

To demonstrate an awareness of leg ulceration management and be able to teach this to others.

To demonstrate an awareness of the appropriate management of fungating wounds and be able to teach this to others.

To demonstrate an awareness of the appropriate management of open abdomen and be able to teach this to others.

To demonstrate an awareness of the appropriate management of the diabetic foot and be able to teach this to others.

To be proficient at aseptic / non-touch technique and be able to teach this to others.

To be proficient at clean technique and be able to teach this to others.

To demonstrates the ability to determine a wound infection and instigate appropriate management. Is able to teach this to others.

To be proficient in holistic wound assessment and be able to teach this to others.

To be proficient in determining appropriate wound management to include wound covering material and be able to teach this to others.

To demonstrate proficiency in the taking of a wound swab from a non-infected wound and from an infected wound. Is be able to teach this to others.

Demonstrates the ability to plan the appropriate care for a patient with a wound; including the use of appropriate treatment objectives to enable evaluation and be able to teach this to others.


Specialist staff (e.g. Tissue Viability Nurse/Vascular nurse/Podiatrist):

In addition to being able to undertake the items below, is also able to assess and audit the completeness of the activities of others in relation to the aspects below.

To be able to undertake a full skin Assessment and be able to teach this to others.

To be able to classify Pressure Ulcers correctly and be able to teach this to others.

To be able to risk assess patients for pressure ulcers using a recognised pressure ulcer risk assessment tool and be able to teach this to others.

To be able to determine the appropriate equipment to use to prevent pressure ulcers including repositioning and be able to teach this to others.

To be able to determine the appropriate equipment to use to treat existing pressure ulcers including repositioning and be able to teach this to others.

To demonstrate an awareness of leg ulceration management and be able to teach this to others.

To demonstrate an awareness of the appropriate management of fungating wounds and be able to teach this to others.

To demonstrate an awareness of the appropriate management of open abdomen and be able to teach this to others.

To demonstrate an awareness of the appropriate management of the diabetic foot and be able to teach this to others.



31

To be proficient at clean technique and be able to teach this to others.

To demonstrates the ability to determine a wound infection and instigate appropriate management. Is able to teach this to others.

To be proficient in holistic wound assessment and be able to teach this to others.

To be proficient in determining appropriate wound management to include wound covering material and be able to teach this to others.

To demonstrate proficiency in the taking of a wound swab from a non-infected wound and from an infected wound. Is be able to teach this to others.

Demonstrates the ability to plan the appropriate care for a patient with a wound; including the use of appropriate treatment objectives to enable evaluation and be able to teach this to others.

Ability to formulate plans of complex care.

Ability to advise staff on the management of patients with wounds.

Ability to devise policies and procedures to direct care relating to tissue viability within the organisation.

Evaluates the care of patients instigated by self and others within the organisation in relation to tissue viability.

32

Appendix 6 Wolverhampton Health Economy Chronic Wounds High Impact Intervention


33


34


35


36

Appendix 7 Heart of England PCT Pressure Ulcer Programme Domain: District Nursing/ allied healthcare professionals

Area: Assessment and treatment of Pressure Ulcers where skilled district

nursing and allied health care professional intervention is required to

ensure effective treatment.

PCT Target: All adults and children with or at risk to pressure ulceration that require

intervention from the district nursing service. (See District Nursing

Referral Criteria)

PAS/Activity Code: PAS Codes required- see EB 399912005 – Pressure sore

D/N Contribution: 1. A holistic assessment of the Service Users status to determine the aetiology of the pressure ulcer utilising Tissue Viability Guidelines (See HOBtPCT Policy – Tissue Viability

Guidelineshttp://pctnet/services/tissueviability/documents.asp)

2. Development of an agreed plan of care in accordance with

service users and their carers.H:\templates\care plans\pressure ulcers\CARE PLAN pressure ulcers HOB.doc

3. Provision of evidence based, quality standardised service. (See HOB tPCT Policy – Tissue Viability Guidelines).

http://pctnet/services/tissueviability/documents.asp 4. Promotion of service user’s concordance and self management

http://www.NICE.org.uk/Guidance/B 5. Raise awareness of health lifestyles/disease prevention. (See

Programme of Care Healthy Lifestyles)

H:\templates\leaflets\Pressure ulcer prevention booklet.doc

6. To act as the coordinator of care where multi professional and multi agency services are required.

7. To ensure that the pressure ulcers have not occurred due to potential

neglecthttp://ncw.pctnet.wmids.nhs.uk/Policies_Admin/PoliciesList.aspx?PCT=hob&ID=347

Target population: All adults and children with or at risk to pressure ulceration that require

intervention from the district nursing service. (See District Nursing

Referral Criteria)

Team Target: All adults and children with or at risk to who require intervention from

district nursing services, in accordance with the District Nursing Referral

Response Times (See District Nursing Referral Criteria).

Intervention:

1. Following a first assessment (See Programme of Care – First Assessment), the service user will have a comprehensive assessment utilising standardised assessment documentation. (See HOB tPCT Tissue Viability Guidelines)

http://pctnet/services/tissueviability/documents.asp



http://www.nice.org.uk/Guidance/B

http://ncw.pctnet.wmids.nhs.uk/Policies_Admin/PoliciesList.aspx?PCT=hob&ID=347

http://ncw.pctnet.wmids.nhs.uk/Policies_Admin/PoliciesList.aspx?PCT=hob&ID=347


37

http://pctnet/services/tissueviability/documents.asp 2. Consent to be obtained in accordance with HOBtPCT Policy

and Procedures.

http://nww.pctnect.wmids.nhs.uk/Policies_Admin/PoliciesList,aspx?PCT=hob&ID=243

3. Record the outcome of assessment, plan of care, and evaluation in accordance with The Guidelines for Clinical Record Keeping

http://pctnect.wmids.nhs.uk/policies_Admin/Policieslist,aspx?PCT=hob&ID=466

4. Assess the requirement and/or use of pressure redistribution equipment in line with Tissue Viability Guidelines


5. Initiate treatment using Wound Care Formulary

http://pctnet/services/tissueviability/documents.asp 6. Report all pressure ulcers that are Grade 3+ (European

Pressure Ulcer Advisory Panel – EPUAP

http://www.epuap.org) utilising the clinical incident form- 7. Care will be reviewed at each visit with formal evaluation and

reassessment of care taking place at a minimum of monthly intervals or earlier if condition changes

8. Ensure appropriate storage of prescribed treatments


9. Ensure safe disposal of clinical waste products


10. Correct procedure for hand washing is adhered to .


11. Service users will be provided with relevant contact details of how to contact the district nursing service and MDT

12. Provide consistent information which ensures that service users are aware of and fully understand the nursing advice and intervention

13. Access interpreters as necessary via the BILCS

servicehttp://pctnet.wmids.nhs.uk/trustwide/corporate/bilcs/index.htm http://nww.pctnet.wmids.nhs.uk/trustwide/corporate/bilcs/index.htm

14. Access to specialist nurse as required via tissue viability service.

http://pctnet/services/tissueviability/documents.asp 15. Supporting written information should be provided using PCT

resources, and/or patient leaflets such as those available from

http://cks.library.nhs.uk/.








http://www.epuap.org/







http://pctnet.wmids.nhs.uk/trustwide/corporate/bilcs/index.htm

http://pctnet.wmids.nhs.uk/trustwide/corporate/bilcs/index.htm


http://cks.library.nhs.uk/


38

Evidence base:

Royal College of Nursing and National Institute of Clinical Excellence

(2005) The Management of Pressure Ulcers in Primary and Secondary

Care. NICE Clinical Guideline September 2005 London, National

Institute for Clinical Excellence http://www.NICE.org.uk/Guidance/B

Tissue Viability Guideline (HOBCT)


Competencies

required:

1. Every registered staff member is responsible for their own continual professional development (CPD) and will keep updated according to current recommendations. This will be monitored using the trust PCT competency

framework.H:\documentation\competency\Pressure Ulcer Competency BEN draft1.doc

2. All registered staff will have an up to date NMC registration, and will remain responsible for updating this as specified.

3. All staff to attend mandatory tissue viability training and complete practical competencies


4. All grades of staff must provide evidence of competency at annual appraisal in line with the Knowledge & Skills Framework (KSF).

Resources required: 1. Access to training as identified in ‘Competencies required’ section

2. Protected time out of role to undertake training 3. Access to equipment necessary to undertake task 4. Access to Heart of Birmingham Policies and Procedures

Partnerships: Service User’s/Carers

Practice Nurses

General Practitioners

Social Workers

Assertive Case Managers( referral forms/ Advanced Nurse

Practitioners

Specialist Services

Occupational therapy( referral forms

Wheelchair services ( referral forms

Dieticians( referral forms

Audit trail: Heart of Birmingham Clinical Audit Programme audit programmes

Tissue Viability Prevalence and Incidence Audit H:\audit\audit

forms\Audit form pressure ulcer 2005.xls

Specific audits to be negotiated with the Director of Nursing Services

http://www.nice.org.uk/Guidance/B




39

and Clinical Development

Standards audit H:\audit\standards audit\standard for pressure

ulcer audit apr 19 v1.doc

.3 monthly pressure relieving equipment audit


40

Appendix 8 Wolverhampton City PCT Care Bundle and Standard Operating Procedure

West Park Rehabilitation Hospital Directorate of Rehabilitation

Nursing

Subject: MOBILITY Date of Implementation: June 2010 Date of Review: July 2013

Care Standard Guideline Number 37 Standard Relating To: Pressure Ulcer management

Care Outcome To ensure the skin integrity is maintained and the risk of deterioration of pressure ulcer formation is reduced healing is optimised.

NURSING CARE

1. Complete care bundle for pressure ulcers.

2. Assess the risk using the Waterlow score, recording assessment in nursing risk record, state

frequency of re-assessment minimum weekly.

3. Record specific needs regarding moving handling the patient on the assessment sheet, avoid sheering force when handling patient.( Refer to physio goal setting care plan.)

4. Alternate position minimum 2 hourly, relieving pressure and observing skin. 5. Record skin condition daily noting any changes 6. Keep skin clean and dry, report any changes in skin condition and pressure areas in nursing records

and to team leader. 7. Ensure adequate dietary and fluid intake, refer to dietician following the nutritional assessment and

record in nursing risk record. 8. Use pillows to support limbs, nurse on appropriate mattress or bed according to risk assessment.

Record in nursing records when specialised pressure relieving methods are used e.g overlay, alternating pressure mattresss. Record time and date when used or changed.

9. Observe for pain on movement, or pain associated with certain positions. Use pain chart as appropriate.

10. Assist with hygiene needs and with any activity of daily living, when required. 11. Conduct regular positioning of patient Using turn charts to record movement 12. Care for wound according to care standard 40, mapping wounds on body chart and dressings required.

Reference:

Tissue Viability policy

Cost effectiveness of Pressure relieving devices for the prevention and treatment of pressure ulcers. Fleurence RL. 2005 Int J Technol Assess Health Care. 2005; 21(3):334-41

The Cost Of Pressure ulcers in the UK. 2004. Age Ageing. 2004;33(3):230-5

American Association of Infection Control Practitioners (APIC); 2001; Position Statement: Clean vs. Sterile: Management of Chronic Wounds; APIC News; March/April 2001;

20-31; www.apic.com; 24/01/05

Chief Medical Officer; 2003; Winning Ways: Working together to reduce Healthcare Associated Infection in England; Department of Health; London

Department of Health (2006). The Health Act 2006.Code of Practice for the Prevention and Control of Health Care Associated Infections.

http://www.apic.com/

41

Pressure Ulcer Care Bundle

Nurse to complete assessments and if any question is answered YES nurse to ask for dietician and physiotherapist to complete their section.

NAME SIGNATURE DATE

History poor skin integrity underlying predisposing condition? Yes / No

Pressure damage on admission.

Yes / No

If Yes complete care plan for wounds and map skin damage

Is the patient at risk nutritionally ? Yes / No

Has the patient got a High risk score on the Waterlow score /immobile? Yes / No

SECTION 1: TO BE COMPLETED by Nurse

Skin Assessment

Actions taken

Identify & treat underlying issues Cognitive

issues. Blood test, , TPR, current medicines. continence

Actions taken

Wound Care Chart Commenced Completed by

Commence repositioning chart using generic Completed by


42

observation chart (obs)2

Environment & equipment review. Consider use of

Pressure relieving mattress/ cushions visibility by nursing staff

Actions taken

SECTION 2: TO BE COMPLETED BY PHYSIOTHERAPIST

Mobility review. Consider intervention required, and

mobility plan.

SIGNATURE DATE

Action taken

SECTION 3: TO BE COMPLETED BY DIETICIAN

Nutritional dietary needs. Consider food supplements ,

and vitamins, minerals , mechanical feeding .

SIGNATURE DATE

Action taken

43

Pressure Ulcer Prevention Daily Intervention.

Tick in each box to state action completed. Write in date, time and signature

in space provided .Record evaluation or changes on the on care plan.

Complete at least once per day

Patient Name. _____________________________________

DOB. ______________________________________

Hosp. No. ______________________________________

ACTION Date/

Time

Skin inspection daily

Refer to Tissue

Viability Review if

deterioration occurs

Wound chart

reviewed/Waterlow

risk

Pressure relieving

equipment in Use

State Mattress /

cushions in use on care

plan

Mobility regime –

adhered to as on care

plan

Skin condition checked

after sitting out on

care plan


44

If wound reviewed

recorded changes on

wound chart

Indicate any further

areas of pressure

damage on care plan

Nurse Signature

45

Appendix 9 Example: Stoke on Trent Community Health Services Primary Care Foot Ulcer

Pathway

Foot ulcer identified by:

GP

Practice Nurse

District Nurse

Other HCP

Community Care Home Staff

REFER : 24 WORKING HOURS

Problem

Sudden Onset Cold Foot

New Hot Foot

and

Emergencies

Refer to Secondary Care Pathway

Primary Care

Community Podiatrists

Healed

Refer back to Community Podiatry

Deteriorated

Refer to Secondary Care Pathway

Complex Wound Clinics run by Advanced Podiatrists in Diabetes

Located at: Bentilee, Biddulph, Fenton, Hanley,

Kidsgrove, Meir, Milehouse, Smallthorne, Tunstall

OR

Multidisciplinary Complex Wound Clinics

Currently located at Leek, Biddulph, Milehouse and Cheadle

run by

TVNs and Advanced Podiatrists in Diabetes

Fast Track Access to Secondary care

OR

Consultant Led Multidisciplinary Complex Wound Clinics

at

Bentilee, Haywood Hospital and Longton Cottage Hospital

No progress after 4

weeks or deterioration


46

Appendix 10 Example: Stoke on Trent Community Health Services Secondary Care Foot Ulcer

Pathway

Problem

Secondary Care - All

referrals must be VIA GP

Chronic Foot Ulcer

Not responding to community treatment

or deteriorating.

Tendon/joint/bone exposed

Sudden Onset Cold Foot

Ischaemic/Necrotic

ABPI <0.5 +

tissue damage

New Hot Foot

Red/hot/swollen

ie. Charcot arthropathy suspected

Emergencies

Severe infection

Spreading cellulitis

GP referral to:

Acute (Medical) Assessment Unit

Or Surgical Assessment Unit

– if debridement required

GP referral to:

Vascular Surgeons

Via

Surgical Assessment Unit - same day

GP referral to:

Vascular/Diabetes Team

Via COPD Urgent Appointment 1-2/52

GP referral to:

Via Diabetes Team for diagnosis then to

Orthopaedic Surgeons Same day

Shared care

to include;

Podiatry, Tissue Viability, Vasc.

Nurse Practitioner, Orthotists,

Biomechanics etc.

47

Appendix 11 Example: Stoke on Trent Community Health Services New Patient Referral Pathway

Triage

Daily – 24hrs

Formal Training

Experienced Staff

30mins per day

Urgent

Offered appointment

within 1-7 working days

Diabetes

Offered appointment/dom

within 1 month

Non-urgent

Offered appointment/dom

within 1 month

Assessed

(and treated if necessary)

Assessed


Assessed


Outcome

Discharge

Single treatment and

discharge

Short-course of treatment

Planned treatment

programme

Outcome

Low risk

(annual assessment

PN/GP)

Increased risk – no

podiatry need

(annual assessment

PN/GP)

Increased risk – podiatry

need

(treatment 3-6 months)

High risk

(treatment 1-3 months)

Ulcerated

(follow pathway)

New referral received at

Shelton Primary Care Centre

Norfolk Street

Shelton

ST

from

GP, Practice Nurse, District Nurse,

Tissue Viability, Allied Health

Professional

Outcome

Discharge

Single treatment and

discharge

Short-course of treatment

Planned treatment

programme

48

Appendix 12 - Bradford Teaching Hospitals NHS Foundation Trust & Bradford and Airedale Teaching Primary care Trust Referral Guidelines

Wound Management Policy

Referral Procedure The wound care and tissue viability service including the leg ulcer service and the diabetic foot clinic are

designed to optimise patient care and to achieve best outcomes for patients in a cost effective

framework. Although some wounds may require direct referral to the Wound Healing Unit at the

Bradford Royal Infirmary for the majority of wounds the process is based around an integrated service

with progressive referral pathway from the general nursing teams, through the community and hospital

Tissue Viability Nursing Service to the specialist Wound Care Unit. Progression depends on:-

Wound complexity and/or aetiology

Treatment outcome review

Treatment availability

Failure to manage symptoms such as pain, odour or exudate

Need to manage associated condition(s)

Patient choice

Referral Criteria The criteria for progression along the referral pathway are:

need, wound complexity, co-morbidity, response to treatment and existing National policies (e.g. NSF

relating to diabetic foot management)

Health care practitioners should refer a patient for specialist advice to the community Tissue Viability

Nursing Service or Hospital Wound Care Team if:


49

The patient requires a more detailed assessment or management advice is required

A wound that falls outside the field of knowledge or experience of the practitioner

If there are problems with investigations such as Doppler ankle brachial pressures (ABPI)

For any patient where the wound fails to progress or infection, exudate, pain, odour or necrotic tissue is a management problem

For patients with pressure ulcers o The wound is a grade 3 or 4 pressure ulcer o The pressure ulcer is deteriorating or difficult to manage o The ulcer is on the heel and requires Doppler assessment o Where adult protection issues may require evaluation

For all patients with diabetic foot ulcers (including grade 3 and 4 pressure ulcers on the heel) o Co-ordinate care with Diabetic Foot Clinic in line with NSF and Local PACE guidelines

For patients with surgical wounds (in conjunction with the appropriate surgical team) o Progress to healing requires VAC therapy o Progress is delayed or is affecting patient quality of life

For patients who are receiving or require advanced therapy. (e.g. topical negative pressure or larvae therapy)

o Assessment of need/appropriateness o Assessment of progress and review of outcome

For patients with malignant fungating wounds o To review treatment options to maintain symptom control

Health care practitioners should refer a patient to the leg ulcer service for:-

A below the knee wound – no improvement/static after 4 weeks

Failure to control symptoms such as venous eczema, pain or exudate

Where diagnosis is uncertain

Where concordance issues affect care

Patient choice

Health care practitioners should refer directly to the Wound Healing Unit for:-

Failure to make adequate progress- no improvement/static after 12 weeks of appropriate treatment.

Failure to control symptoms (pain, odour, exudate) despite input from the tissue viability team or community leg ulcer service

Assessment for venous surgery to prevent recurrent ulceration

Requirement for specialist input related to wound complexity or co-morbidity

Wound requires care only available within a specialist centre

A patient with a leg wound and low ABPI (<0.8) or if assessment or symptoms suggests ischaemia

Referral indicated by National policy or framework

Referral to other specialist services may be appropriate when:-


50

When contact dermatitis complicates care – referral for Dermatological opinion may be appropriate

When malignancy is suspected - referral to Plastic Surgery or Dermatology combined clinic.

51

Diagram of Referral Criteria to Tissue Viability Service

TISSUE VIABILITY SERVICE

Pressure Ulcers

The wound is grade 3 or 4 pressure ulcer

The wound is deteriorating or difficult to manage

The ulcer is on the heel and required Doppler assessment

Where adult protection issues may require evaluation

Surgical Wounds

Progress to healing requires vacuum therapy

Progress is delayed [compared to expected healing time]

Progress is affecting the quality of life [for the patient]

General - any wound where:-

Patient requires more detailed assessment [than is

available in the current setting/area of expertise]

Wounds falls outside the field of knowledge of the

practitioner

The ankle brachial pressure (ABP) gives cause for concern

Wound fails to progress OR

Infection, pain, exudate, odour or necrotic tissue is

unmanageable

All fungating wounds

Any patient requiring advanced therapy